Arbors West
Inspection history, citations, penalties and survey trends for this long-term care facility in West Jefferson, Ohio.
- Location
- 375 West Main Street, West Jefferson, Ohio 43162
- CMS Provider Number
- 365426
- Inspections on file
- 26
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Arbors West during CMS and state inspections, most recent first.
A cognitively intact resident with Huntington’s disease and other conditions was participating in chair exercises when a CNA used a personal cellphone to record the resident lifting her leg above her head, without any signed photo release or consent from the resident’s POA. Two other CNAs watched the event and did not report it. Other staff later observed the CNAs laughing and viewing the image on the phone. Review of incident reports, staff statements, and the facility’s social media policy confirmed that the recording was taken in the work area using a personal device and that facility policy prohibits taking or sharing resident photos or videos without prior written permission.
The facility failed to maintain proper hand hygiene during food service, affecting all residents. A staff member contaminated food by using a soiled glove while taking food temperatures. Additionally, a soiled scoop was used during tray line service, contrary to facility policy requiring clean utensils. The facility's policy mandates adherence to federal guidelines for meal service.
The facility failed to maintain clean and safe grounds, with significant litter of cigarette butts observed along the sidewalk to the smoking area. Two residents confirmed the issue, noting that residents did not use the provided dispensing devices. An LPN confirmed the litter and identified potential fire hazards due to piles of debris mixed with cigarette butts. The facility's policy indicated maintenance was responsible for maintaining safe grounds.
The facility failed to conduct interdisciplinary care conferences for three residents, affecting their involvement in care planning. A resident was not invited to any conferences, while another's family was rarely invited. Additionally, a resident's care plan lacked updates for anticoagulant use, despite receiving the medication. These deficiencies were confirmed by staff interviews and record reviews.
The facility failed to timely address pharmacy recommendations for four residents, leading to delays in medication changes. Recommendations for obtaining a TSH level, discontinuing Lorazepam and Megace, and reducing doses of Zoloft and Trazodone were not acted upon promptly. The facility's policy requires timely action on MRR irregularities, which was not followed.
The facility failed to prepare pureed food to the required consistency for residents with dietary needs. A staff member was observed preparing pureed peas, which contained lumps and pieces despite repeated blending. The Regional Dietary Contractor confirmed the improper consistency, which was corrected only after surveyor intervention. The facility's policy mandates a pudding mousse-like consistency for pureed foods.
The facility failed to ensure resident fund authorization forms were properly witnessed, affecting two residents. One resident, cognitively impaired, had an illegible signature without witness signatures, while another, cognitively intact, had a legible signature but also lacked witness signatures. The Business Office Manager was unaware of the requirement for witness signatures, contrary to facility policy.
The facility failed to provide required spenddown notifications to two residents whose account balances exceeded $1800. One resident, with a BIMS score of 4, had balances consistently over the threshold, reaching $3707.29. Another resident, with a BIMS score of 00, had balances over $19,000. Despite the facility's policy requiring notifications when balances reach $1800, these were not consistently provided, as confirmed by the Business Office Manager.
A facility failed to create a comprehensive care plan for a resident with PTSD, despite the resident's severe cognitive impairment and multiple diagnoses. Interviews with the DON and a social worker confirmed the absence of a care plan addressing PTSD, contrary to the facility's policy requiring person-centered care plans for all residents.
The facility failed to communicate with the dialysis center for a resident with end-stage renal disease, diabetes, heart failure, and cognitive communication deficit. The LPN confirmed that no documentation was sent to the dialysis center, and the DON acknowledged the lack of communication, as the dialysis center stopped completing their part of the form. The facility's policy required coordination and reporting to the dialysis provider, which was not followed.
A facility failed to provide trauma-informed care for a resident with PTSD, who was severely cognitively impaired and had multiple diagnoses. Despite receiving psychiatric services, the resident's medical record lacked documentation of preferences, trauma triggers, or interventions to prevent re-traumatization. Interviews confirmed the absence of an independent PTSD assessment, as residents were referred to psychiatric services without further facility assessment.
A resident was prescribed Quetiapine Fumarate (Seroquel) for insomnia despite not having a psychotic disorder, which is necessary for such medication. The facility failed to act on a pharmacist's recommendation to discontinue the medication, resulting in its continued use without an appropriate diagnosis.
A medication error occurred when a nurse administered Lisinopril and Propranolol to a resident with a systolic blood pressure of 105 mmHg, despite orders to hold these medications if the systolic blood pressure was below 110 mmHg. The nurse was unaware of the parameters, leading to a medication error rate of 6.45% in the facility.
A resident receiving hospice care had incomplete medical records, with the last hospice note being from a care team meeting. The hospice communication notebook at the nurses' station was also missing visit documentation. Interviews with staff confirmed the absence of hospice notes, affecting the facility's record-keeping for the resident.
A facility failed to prevent contamination during medication administration when an RN handled medications with bare hands before placing them in a medication cup. The RN was unaware of the proper procedure to avoid touching pills directly, which was contrary to the facility's policy requiring medications to be administered in a manner preventing contamination or infection.
A facility failed to follow ordered parameters for blood pressure medication administration for a resident. An RN administered Lisinopril and Propranolol despite the resident's blood pressure being below the prescribed threshold for withholding these medications. The RN was unaware of the hold parameters, contrary to the facility's medication administration policy.
A former LPN misappropriated pain medications from three residents, affecting their prescribed regimens. The facility discovered discrepancies in medication counts and surveillance footage confirmed the LPN's actions. Despite policies requiring controlled substance counts, the misappropriation occurred, impacting resident care.
Two residents experienced significant delays in call light responses, with one resident waiting over an hour for incontinence care and another waiting 20 minutes for assistance with tube feeding. Staff interviews confirmed that long wait times were typical, and observations noted several staff members, including the DON and Unit Manager, walking past activated call lights without responding. Facility policy emphasized the importance of timely responses, highlighting the deficiency in care.
A resident in a LTC facility was observed without a sheet on her mattress over several days, despite being cognitively intact and requiring assistance with daily living activities. After moving rooms, the resident requested a sheet but was denied. Staff confirmed that the bed should have had a sheet, indicating a failure to maintain a homelike environment.
A resident with multiple medical conditions did not receive scheduled showers, resulting in an unkempt appearance. Despite being cognitively intact and requiring assistance, the resident's shower schedule was inconsistently documented, and staff reported frequent refusals and inadequate staffing. The DON was unaware of schedule discrepancies and missing documentation.
A resident with multiple health conditions, including diabetes and respiratory issues, did not receive a full and nutritious meal as per their carb-controlled diet plan. The meal provided was incomplete, missing key components like soup and bread, leading the resident to order additional food. Staff interviews revealed a lack of awareness and adherence to the resident's dietary preferences and facility policy, resulting in non-compliance.
Unauthorized Cellphone Recording of Resident Without Consent
Penalty
Summary
The facility failed to ensure the confidentiality and privacy of a resident’s personal and medical information when a CNA used a personal cellphone to record the resident without consent. The resident, admitted with diagnoses including Huntington’s disease, anxiety, and protein calorie malnutrition, was cognitively intact with a BIMS score of 13 and required one-person assistance with ADLs. During a chair exercise activity in the dining room, the CNA observed the resident lifting her leg above her head and took out her cellphone to take a picture/video of the resident. Two other CNAs stood nearby, watched the resident performing the exercises, and witnessed the recording being made but did not report it. The resident’s POA later confirmed that she had not given authorization for any photos or videos to be taken of the resident. Multiple staff interviews and document reviews corroborated that the recording occurred and that it involved the resident’s image being captured without prior authorization. The Activities Director and Business Office Manager both observed the three CNAs outside the dining room laughing and looking at a cellphone image of the resident with her leg pointed straight up. Review of the incident reports and staff statements confirmed that the recording was made on a personal cellphone in the work area. The Admissions Coordinator verified that there was no signed photo release authorization for the resident, and review of the facility’s Social Media Policy showed that employees are prohibited from using personal electronic devices in the work area without written approval and from taking or sharing resident photos or videos without prior written permission from the resident or authorized agent. Observation of the video by the Administrator and DON further confirmed that the resident had been recorded without authorization, constituting a breach of confidentiality and privacy.
Failure to Maintain Proper Hand Hygiene During Food Service
Penalty
Summary
The facility failed to maintain proper hand hygiene during food service, which had the potential to affect all residents. During an observation, a staff member was seen taking temperatures of food items and inadvertently contaminating the food. The staff member placed a thermometer in mashed potatoes, getting a piece of potato on her thumb and pointer finger. Without changing gloves, she submerged her soiled fingers into the gravy, confirming that her dirty glove was in the gravy mixture. In another instance, a staff member was observed scooping augratin potatoes when the scooper fell into the pan and became soiled. Despite this, a Regional Dietary Contractor picked up the soiled scoop and continued to use it for tray line service, handling other food items with it. The staff member acknowledged that if a scoop or service item falls into the food, it should be replaced with a clean one. The facility's policy on meal distribution and infection control, dated February 2023, mandates that meal service should follow federal guidelines.
Facility Grounds Littered with Cigarette Butts
Penalty
Summary
The facility failed to maintain the grounds in a clean and safe manner, specifically regarding the accumulation of cigarette butts on the property. Observations on two separate occasions revealed significant litter of cigarette butts along the sidewalk from the east hall exit to the designated smoking area, with hundreds of cigarette butts visible. Interviews with two residents confirmed that the smoking area, sidewalk, and grass area outside the fence were littered with cigarette butts, as residents did not use the dispensing devices provided and instead tossed their cigarette butts anywhere. An LPN confirmed the presence of hundreds of cigarette butts along the sidewalk and behind the fence, noting that the yard company was responsible for picking up trash and cigarette butts. The LPN also identified piles of dead plant debris mixed with cigarette butts, which could pose a fire hazard next to the wooden fence. The facility's policy on Preventative Maintenance indicated that maintenance was responsible for ensuring the building and grounds were maintained in a safe and operable manner.
Deficiencies in Care Conferences and Care Plan Updates
Penalty
Summary
The facility failed to ensure that interdisciplinary quarterly care conferences were completed for three residents, affecting their involvement in care planning. Resident #7, who was cognitively intact, reported not being invited to any care conferences in the previous year, despite documentation indicating a conference was held. Similarly, Resident #9's family expressed that they were only invited to a care conference once in the last year, although the facility's records showed a conference was held. Interviews with regional staff confirmed the lack of evidence for completed care conferences for these residents. Resident #36, who was moderately cognitively impaired, also did not have documented care conferences. The resident expressed a desire to be more involved in their care, but the facility only documented a quarterly mood evaluation by the social worker without a summary of care discussions or participant details. The social worker confirmed the absence of documented care plan meetings, indicating that the resident's care discussions were informal and not part of a structured conference. Additionally, the facility failed to update the care plan for former Resident #51 regarding the use of an anticoagulant medication. Despite receiving Eliquis for embolism and thrombosis, the resident's care plan lacked focus, goals, or interventions related to the medication. The Director of Nursing confirmed this oversight, which was inconsistent with the facility's policy to develop comprehensive care plans that address residents' medical needs.
Delayed Response to Medication Regimen Reviews
Penalty
Summary
The facility failed to timely respond to monthly medication regimen reviews (MRR) for four residents, leading to deficiencies in addressing pharmacy recommendations. For Resident #53, the pharmacist recommended obtaining a thyroid stimulating hormone (TSH) level on 02/05/25, but the provider did not address this until 03/18/25, with the TSH level ordered on 03/25/25. The Director of Nursing (DON) confirmed that the expectation is for recommendations to be addressed by the provider on the next visit, which occurs at least weekly. Resident #62's MRR on 02/05/25 included recommendations to discontinue Lorazepam and reduce doses of Zoloft and Trazodone. The provider agreed to these changes on 03/18/25, but the interdisciplinary team did not meet to review these recommendations until 03/25/25, delaying the implementation of the medication changes. Similarly, for Resident #73, a recommendation to discontinue Megace due to the risk of deep vein thrombosis was made on 02/05/25, but the provider did not respond until 03/18/25, and the medication was not discontinued until 03/25/25. Resident #32's MRR on 02/05/25 recommended discontinuing Seroquel, which was being used for sleep in a patient with dementia. The physician agreed to discontinue the medication on 03/18/25, but it was not acted upon until 03/24/25. The facility's policy requires MRR irregularities to be reported and acted upon within 10 working days, but this was not adhered to, resulting in delayed responses to pharmacy recommendations for these residents.
Improper Consistency of Pureed Food
Penalty
Summary
The facility failed to ensure that pureed food was prepared to the proper consistency, as required for residents with specific dietary needs. During an observation, a staff member was seen preparing pureed peas by adding broth to the mixture in a roboku blender. Despite repeated blending and tasting, the mixture contained significant amounts of food on the sides, including visible lumps and pieces of peas. The Regional Dietary Contractor confirmed the presence of chunks and full skins of peas in the mixture. The facility's policy requires pureed foods to be made to a pudding mousse-like consistency, which was not achieved until after surveyor intervention.
Failure to Witness Resident Fund Authorizations
Penalty
Summary
The facility failed to ensure that resident fund authorization forms were properly witnessed, affecting two residents out of seven authorizations reviewed. Resident #12, who was cognitively impaired with a BIMS score of six, had an authorization form dated 04/24/24 with an illegible signature and no witness signatures. Resident #36, who was cognitively intact with a BIMS score of 12, had an authorization form dated 04/20/23 with a legible signature but also lacked witness signatures. The facility's policy requires that authorization forms be signed by the resident or responsible party and witnessed by an individual not associated with the facility when required by the state. During an interview, the Business Office Manager (BOM) confirmed that the authorizations for both residents were not witnessed. The BOM was unaware that witness signatures were necessary, believing they were only required if the resident was unable to sign. This oversight indicates a lack of adherence to the facility's policy regarding resident fund authorizations, which mandates witness signatures to ensure the proper management of residents' financial affairs.
Failure to Provide Spenddown Notifications
Penalty
Summary
The facility failed to provide spenddown notifications to residents when their account balances exceeded $1800, as required by their policy. This deficiency affected two residents, both of whom had account balances over the threshold. Resident #17, who was cognitively impaired with a BIMS score of 4, had a personal fund balance that consistently exceeded $1800 from January 2024 to March 2025, reaching as high as $3707.29. Despite the high balances, spenddown letters were not consistently provided monthly, as required. Resident #43, also cognitively impaired with a BIMS score of 00, had a personal fund balance that significantly exceeded the threshold, with balances over $19,000 for several months in 2024. The resident's balance remained above the $1800 threshold into 2025, yet spenddown notifications were not provided monthly. The facility's policy required that residents be notified when their account balance reached $1800, but this was not adhered to. An interview with the Business Office Manager confirmed that spenddown letters were not provided monthly for residents who were over-resourced. The facility's policy, dated February 2018, stated that residents should be notified when their account balance reaches $1800, but this was not consistently followed, leading to the deficiency.
Failure to Develop Comprehensive Care Plan for PTSD
Penalty
Summary
The facility failed to develop an accurate and comprehensive care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was admitted with multiple diagnoses including cerebral infarction, hemiplegia, type two diabetes mellitus, fibromyalgia, dementia, depression, and PTSD, was found to have no documented care plan addressing PTSD or potential triggers. The annual minimum data set (MDS) indicated severe cognitive impairment and psychiatric/mood disorders, yet the care plan lacked specific interventions for PTSD. Interviews with the Director of Nursing (DON) and a social worker confirmed the absence of a care plan for the resident's PTSD. The facility's policy mandates the development of a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to address medical, nursing, and psychosocial needs identified in the resident's comprehensive assessment. However, this policy was not adhered to in the case of the resident with PTSD, as evidenced by the lack of a care plan for this specific condition.
Failure to Communicate with Dialysis Center for Resident Care
Penalty
Summary
The facility failed to ensure proper communication with the dialysis center for a resident requiring dialysis services. This deficiency affected a resident with end-stage renal disease, diabetes, heart failure, and cognitive communication deficit. The medical record review revealed that the facility did not maintain a dialysis communication binder, and all documentation was located in the electronic medical record. The Licensed Practical Nurse (LPN) confirmed that the facility did not send any documentation to the dialysis center and believed the center did not have access to the facility's medical records. The Director of Nursing (DON) confirmed the lack of communication with the dialysis center, stating that the center had stopped completing their part of the communication form, leading the facility to cease sending it. The pre and post-dialysis assessments in the electronic record were not specific to dialysis sessions, as they were based on vitals taken every 12 hours rather than immediately before and after dialysis. The facility's policy required coordination between the facility and the dialysis provider, including providing a report to the dialysis provider on each treatment day, which was not adhered to in this case.
Lack of Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide individualized trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was admitted with multiple diagnoses including cerebral infarction, hemiplegia, type two diabetes mellitus, fibromyalgia, dementia, depression, and PTSD, was found to be severely cognitively impaired with a BIMS score of five out of 15. Despite receiving psychiatric services and medications for depression and PTSD, the medical record lacked documentation of the resident's preferences, trauma triggers, or interventions to prevent re-traumatization. Interviews with the Director of Nursing and a social worker confirmed the absence of an independent PTSD assessment, as residents with PTSD were referred to psychiatric services without further facility assessment.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident had an appropriate diagnosis for the use of an antipsychotic medication, specifically Quetiapine Fumarate (Seroquel). The resident, who was admitted with diagnoses including malnutrition, Alzheimer's disease, heart failure, muscle weakness, and atrial fibrillation, was prescribed Seroquel for insomnia. However, the resident did not have a psychotic disorder, which is necessary for the use of such medication. Despite recommendations from a pharmacist to evaluate and discontinue the medication due to the lack of an appropriate diagnosis, the medication was continued until it was eventually discontinued on 03/25/25. The Director of Nursing confirmed that the medication regime review was not acted upon in a timely manner, and the resident continued to receive Seroquel without a warranted diagnosis. The facility's policy states that psychotropic drugs should only be administered when necessary to treat a specific condition, as diagnosed and documented in the clinical record. The failure to adhere to this policy resulted in the unnecessary administration of an antipsychotic medication to a resident without a proper diagnosis.
Medication Administration Error Due to Unawareness of Parameters
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in a medication error rate of 6.45%. This deficiency affected one resident out of three observed for medication administration. During an observation, a registered nurse prepared and administered seven medications to a resident, including Lisinopril and Propranolol, both of which were to be held if the resident's systolic blood pressure was less than 110 mmHg. The resident's blood pressure was recorded at 105/69, yet the medications were administered. The nurse confirmed she was unaware of the parameters to hold the medication, despite the facility's policy requiring the person administering medications to obtain and record vital signs and hold medications for vital signs outside the physician's prescribed parameters.
Incomplete Hospice Documentation for Resident
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident who was receiving hospice services. The resident, who had multiple diagnoses including dementia and chronic kidney disease, was unable to be interviewed due to communication difficulties. The review of the resident's electronic medical record showed that the last hospice note was from an interdisciplinary team meeting, and there were no subsequent hospice notes uploaded. Additionally, the hospice communication notebook at the nurses' station, which should have contained visit documentation, was found to be incomplete with only an admission face sheet and blank sections for hospice team communication. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed the absence of hospice communication notes in the hospice binder. The Director of Nursing acknowledged that the nursing staff relied on the binder for hospice communication and verified that the last note in the electronic medical record was from the care team meeting. This deficiency affected the facility's ability to maintain accurate and complete records for the resident receiving hospice care.
Medication Administration Deficiency Due to Improper Handling
Penalty
Summary
The facility failed to ensure medications were administered in a manner to prevent contamination or infection, affecting one resident during medication administration observations. On the morning of March 26, 2025, a Registered Nurse (RN) prepared seven medications for a resident using a unit dose dispensing system. The RN removed each medication from its package and placed it into her ungloved hand before dropping it into a medication cup. During an interview, the RN confirmed that she was unaware that she should not touch the pills with her bare hands and should either place the pills directly into the cup or wear gloves. A review of the facility's Medication Administration policy, last reviewed on January 17, 2023, confirmed that medications are to be administered as prescribed by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.
Failure to Follow Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to adhere to the ordered parameters for administering blood pressure medications to Resident #240. During an observation, RN #136 prepared and administered seven medications, including Lisinopril and Propranolol, to the resident. The resident's blood pressure was recorded at 105/69, which was below the prescribed threshold of 110 mmHg for withholding these medications. Despite this, RN #136 administered the medications, later confirming she was unaware of the hold parameters. The facility's medication administration policy, last reviewed on 01/17/23, requires staff to obtain and record vital signs and hold medications if vital signs fall outside the physician's prescribed parameters.
Medication Misappropriation by LPN
Penalty
Summary
The facility failed to protect three residents from misappropriation of their pain medications by a former Licensed Practical Nurse (LPN). The residents involved had various medical conditions requiring pain management, including multiple sclerosis, chronic obstructive pulmonary disease, and paraplegia. The care plans for these residents included administering medications as ordered and monitoring their effectiveness. However, discrepancies in medication counts were discovered, indicating that the prescribed Gabapentin was not administered as documented. The incident came to light when the Director of Nursing noticed inaccuracies in the medication counts for the affected residents. Surveillance footage revealed that the former LPN diverted medication by removing pills from blister packs and placing them into a generic container. This misappropriation was confirmed when the LPN admitted to the missing medications during an inquiry by the facility's administrator. The facility's policy required controlled substances to be counted at the end of each shift, with discrepancies reported immediately. Despite this policy, the misappropriation occurred, affecting the residents' medication regimens. The facility's failure to adhere to its own procedures allowed the LPN to misappropriate medications, impacting the care of the residents under her supervision.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to respond to call lights in a timely manner, affecting two residents. Resident #35, who was cognitively intact and required assistance with various activities of daily living, had her call light activated for incontinence care from approximately 8:00 A.M. until 9:25 A.M. on the day of observation. Interviews with the resident and CNAs revealed that long wait times for call light responses were typical, with staff often too busy to respond promptly. The resident reported that requests for showers or incontinence care were often delayed by one to two hours, or staff would not return after initially acknowledging the request. Resident #49, who was also cognitively intact and had a feeding tube, experienced a delay in response to his call light, which had been activated for about 20 minutes due to concerns about his tube feeding. Observations noted several staff members, including nursing staff, CNAs, the DON, and the Unit Manager, walking past the room without responding to the call light. An LPN confirmed that the call light had been on for a long time and acknowledged that all staff were responsible for answering call lights, with an expectation of a response within about five minutes. The facility's policy and protocol emphasized the importance of timely responses to call lights, indicating that failure to do so could be considered neglect.
Failure to Provide Linens for Resident's Bed
Penalty
Summary
The facility failed to ensure a comfortable and homelike environment for Resident #35 by not providing linens on her bed. Resident #35, who was cognitively intact and required assistance with various activities of daily living, was observed multiple times over three days without a sheet on her mattress. Instead, she had only one sheet/blanket covering her while she slept. This lack of proper bedding was confirmed through observations and interviews with the resident and staff. Resident #35 had recently moved rooms, and it was noted by Certified Nursing Aides that she had a sheet on her bed in her previous room. However, since the move, the mattress on her bed had been without sheets. The resident had requested a sheet, but her request was denied. A Licensed Practical Nurse confirmed that the type of bed and mattress used by the resident should have a sheet, and acknowledged that staff should have placed a sheet on the mattress.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that a resident received showers as scheduled, affecting one resident out of three reviewed for Activities of Daily Living (ADLs). The resident, who was cognitively intact, required assistance with showering and personal hygiene due to multiple medical conditions, including diabetes, spinal muscular atrophy, and functional quadriplegia. Despite being scheduled for showers on specific days, records showed inconsistencies in documentation, with several instances where showers were not recorded as provided or refused. Observations revealed the resident appeared unkempt, with greasy hair and dirty nails, indicating a lack of proper hygiene care. Interviews with the resident and staff revealed discrepancies in the shower schedule and a lack of adequate staffing to provide the necessary care. The resident expressed a preference for bed baths and reported receiving showers less frequently than scheduled. Staff confirmed the resident's disheveled appearance and noted frequent refusals of ADL care. The Director of Nursing was unaware of the discrepancies in the shower schedule and acknowledged missing documentation for several shower instances. This deficiency was investigated under multiple complaint numbers.
Failure to Provide Nutritious Meal to Resident
Penalty
Summary
The facility failed to provide a full and nutritious meal to a resident, identified as Resident #35, who was part of a group reviewed for nutritious meals. Resident #35, who was cognitively intact and required setup assistance for eating, had a medical history that included diabetes, spinal muscular atrophy, chronic myeloid leukemia, respiratory failure with hypoxia, pulmonary fibrosis, and bipolar disorder. The resident was on a carb-controlled diet, and the menu for the dinner meal included lentil soup, whole wheat crackers, tuna salad on wheat bread, marinated tomato salad, and a half slice of dessert. However, the resident received a meal consisting only of shredded lettuce with tomato and onion salad and two slices of lunch meat, missing several components of the planned meal. Interviews with staff revealed discrepancies in meal preparation and delivery. A CNA confirmed the resident received an incomplete meal, and the Director of Nursing was unaware of the missing items. The Kitchen Manager acknowledged the resident's preferences and confirmed that the resident was not given half of her meal, which led to the resident frequently ordering food from DoorDash. The resident expressed a preference for wraps instead of open-faced sandwiches and confirmed ordering additional food due to insufficient meals. The facility's policy on menus and adequate nutrition was not followed, as the resident's nutritional needs were not met, leading to non-compliance under a complaint investigation.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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